For students entering nursing, clinical decision making is a skill to be learned. Initially, nursing students are concerned with procedures, how to start an intravenous line (IV) or insert a foley catheter. While these technical skills are important, clinical decision making provides the framework for nursing care. In order to facilitate this process, nursing faculty work with students in clinical to apply this concept and then require them to record to record their critical thinking process in a nursing concept map. Clinical decision making utilizes the nursing process; assess, plan, intervene and evaluate . A cyclical process, students initially perceive the scientific process as a static process versus a cyclical one. Faculty, when working with ten students in the clinical arena are unable to observe all students due to the high intensity of patient care. Therefore, the concept map provides evidence of their thought process. Faculty then review and evaluate these concept maps specific to the patients assigned to the students in the clinical environment.

Nursing Process

– Assess– Plan– Intervene– Evaluate

Initially, students when introduced to clinical are concerned with the questions of, “How do I know how to take care of a patient?” and “What do I do first?” Though faculty differ in their technique, this faculty asks students “what is your goal?” in relation to their assigned patient. Demonstrating the nursing process via a peanut butter sandwich reinforces the concept and makes it reachable. The faculty asks how do we get to the goal of eating the peanut butter sandwich (see Figure 1), in other words, “how do we get there (see Figure 2)? The steps for making a peanut butter sandwich are reviewed – students assess what is needed, plan the steps, implement (intervene) the steps and evaluate the process. Being specific in the plan requires identifying the desired bread and peanut butter, as well as having the proper utensils to make the sandwich. Further, it includes how the sandwich is made. Faculty follow the student directions in making the sandwich, as placing peanut butter on one side, both sides or two separate slices of bread. Many of us make the peanut butter sandwich without regard to the process. Lastly, students are directed to the cyclical process of clinical decision making (see Figure 3). Students are reassured as they learn clinical decision making, over time the clinical decision making process will become instinctual secondary to their knowledge base.

The Goal

Figure 1

And the steps are...

Figure 2

Nursing Process

Figure 3

Following this discussion and ingestion of the peanut butter sandwiches, students are given a patient problem they will see in their obstetrical clinical, ie. pain during labor. Using the color coded concept map, students complete the concept map as a group.

The concept map is reviewed by faculty and students specific to the nursing process as evidenced by their clinical decision making. Each week in clinical, students are assigned a patient. Each patient is an individual and unique with an identified problem requiring nursing care. Students are required to identify one specific patient problem, the primary problem, and prepare a concept map for this patient (appendix A). Though some interventions are not possible during the clinical time, students are required to identify all pertinent interventions to the patient problem. Each nursing intervention is to have scientific rationale for its inclusion and the source documented. Measurable outcomes are required for evaluation . Concept maps are due to the faculty approximately five days following patient care. Faculty review these maps and provide constructive feedback. Students are strongly encouraged to meet with faculty to discuss questions and concerns regarding faculty comments to facilitate learning.

Over the semester, students begin to integrate the nursing process into their clinical care and develop and strengthen their clinical decision making. With each clinical and concept map, the cyclical process is reinforced. Concluding each semester, students complete an anonymous evaluation of the clinical course, to include assignments as well as the clinical experience. Student comments include, “I hated doing “them” but now I know it in my head,” and “the process makes more sense now.” Consistently, students while lamenting having to complete and the number of concept maps, strongly reinforce its use as a learning tool. As a nursing clinical instructor, I have found the process of introducing the nursing process and clinical decision making via the peanut butter sandwich technique engaging and fun. Subsequently, concept maps over the semester, facilitate the student’s integration of clinical decision making into their daily patient care.